Ruminations by a non-academic general surgeon from the heart of the rust belt.

Wednesday, December 16, 2009

Coumadin and Afib in the Elderly

I cover trauma call for the eastern suburbs of Cleveland at a level II trauma center. Given our patient population, we don't exactly see the Friday Night Gun Club sorts of cases like one would experience at level I urban centers. Ours is more like the Saturday Afternoon Fall Down and Bump Your Head Club. Other than blunt trauma from MVC's, our next most popular mechanism of injury is some little old lady or little old gentleman losing balance, and whacking his/her dome against the floor.

What I find annoying is the high percentage of these elderly patients (many in their 80's and 90's) who are on anti-coagulation therapy for atrial fibrillation. This buys the injured patient a ticket to the ICU and multiple CT scan to make sure there is no delayed intracerebral bleeding. Mucho dinero. Even more annoying is the fact a lot of these people are frequent flyers. You browse through the computer chart and you see three or four admissions over a 2 year period for similar falls.

The rationale behind anti-coagulating people with atrial fibrillation is that you want to reduce the risk of clot formation in the fibrillating heart chambers and subsequent embolic stroke. There's a fairly recent RCT from Scotland (the BAFTA study) that seemed to support the use of coumadin over aspirin even in elderly patients (>75) with afib. But the data showed that, despite the use coumadin, there was still a 1.8% risk of stroke over the course of one year. And the trial didn't use a control of patients without any anti-coagulation; it just compared coumadin versus aspirin.

I find it difficult to wrap my mind around the idea that anybody over the age of 85 needs to be on coumadin for afib. Not because of rationing, mind you, but simply for safety reasons. It's not clear to me that the benefit outweighs the risks, even in the most optimal candidates. Certainly anyone with a history of prior falls, dementia, or a GI bleeding history ought to be excluded; but in this era of fragmented care (hospitalists and subspecialists and lack of communication) it gets harder and harder to make sure that we aren't just mindlessly implementing "best practice recommendations" without looking at the individual patient...

11 comments:

ER Doc
said...

I completly agree. For every one of those patients you see, I scan 15-20 in the ED for minor head bumps. It seems like people get started on medications and then no one ever rationally thinks about the consequences as people age.

and I've had neurologists and cardiologists saying the exact opposite, you see the trauma, they see the strokes... anticoagulation is all a matter of perspective; which is why we do trials. And so far, the trials have supported anti-coagulation.

"of patients without any anti-coagulation; it just compared coumadin versus aspirin"

-probably couldn't get IRB approval for a true control given the astronomical stroke risk in these patients

The warfarin in the elderly issue is very complex. The studies of Afib (AF) and stroke are very convincing that the risk of embolic stroke in AF goes up dramatically with age. It is on the order of 8% per year in the 85 year old patient you are referring to.

The studies of warfarin strongly suggest that if (an important if) a patient's INR is kept in the appropriate range, the risk of stroke reverts to close to the baseline, during the period they are in range.

It is important to consider that if you are judging this issue based on your experiences in the ED, you may have a biased view. This is because you get called to see everyone who has an adverse outcome of warfarin therapy. The 85 year old who does well will not present themselves to you to tell you about the disabling stroke that they did not have.

On the other hand, I am impressed with the number of really good clinicians who tell me they do not believe the RCTs of warfarin therapy in terms of its use in the elderly. They insist that their patients were not in these studies.

I think there is something to these criticisms. The RCTs present little information about their older subjects in terms of functional status, cognitive functioning, and geriatric syndromes such as falls. I suspect the older patients in these studies were by and large healthier elders. We need to know much more about factors such as fall history, functional status, and cognitive functioning impact the risk and benefits of warfarin use in the elderly.

In the interim, there are probably better alternatives than using age based cutoffs for recommendations for warfarin use. I actually think the evidence is pretty compelling that in the non frail elders (ie, good cognitive functioning, good functional status) the benefits of warfarin therapy probably increase with age. This is because the risk of embolic stroke (which warfarin minimizes)increases at a faster rate than the risk of bleeding complications. It is important to recognize that this is not a phenomenon one will observe in day to day ED practice, because the well functioning 85 year olds are not the ones showing up at your ED. Also, as noted, you don't see the patients who are doing well, but would have had a stroke if they were on warfarin.

What to do in the more frail elderly is more complex and uncertain. There are not good data to guide decision making, and you have to use your clinical judgement to decide if the risks of warfarin outweigh the risks of stroke without warfarin.

I see a lot of complications from coumadin, as a hospitalist. But mostly, I see those complications because the patient's INR got out of control because some doc started Levaquin or Bactrim or Amiodarone without thinking about the consequences on INR.

None of this will matter soon as newer anticoagulants that don't require monitoring become clinically available.

Would I treat myself with coumading at 85 years old? I think i would, because I've seen the devastating effects of stroke on this population.

I've also seen the devastating effects Plavix and falls.

The take home point is to live your life well, exercise, eat healthy and try to avoid all the complications that come with a life of not caring about your temple.

And hopefully you can avoid the medication madness that occurs with the sick and walking elderly

"The take home point is to live your life well, exercise, eat healthy and try to avoid all the complications that come with a life of not caring about your temple."

Unfortunately, it's not always that easy. I was diagnosed with lone afib two years ago. I have been a health conscious, non-smoking, non-drinking vegetarian all my adult life. I weigh 120 pounds and have excellent BP and cholesterol. I have cared for my temple well yet I still struggle with this affliction.

lone atrial fibrillation doesn't apply to to the elderly, by definition, so your discussion doesn't apply to the elderly. Besides population studies apply to populations, not individuals. If you take populations of people like yourself, most will thrive and a few won't.

I have more of a question than a comment as I agree, from a logical perspective, but as a caregiver (my mom is 85 with a-fib and Parkinson's Disease)... I feel like I am walking on a tightrope because she will be taken off of coumadin within the next few days and I fear her suffering a stroke. She has a very high fall risk and we have seen our share of ER visits. Internal bleeding or stroke??? It feels like I must decide her fate. Her cardiologist will keep her on baby aspirin... will this provide some benefit to clot prevention?

Anonymous: I have an irregular heart beat and I know I have had it all my life. Being in my seventh decade, I often wonder if, at some time during an exam some Dr. will try to convince me I need to take an anti coagulate. Sorry, I think it is way over used. I had a Dr. tell me thirty years ago that I will die if I don't get teatment for the IHB. Sadly, he passed away, my Dr. said don't worry about it. I don't intend to ever take the stuff.

My father lived healthfully for 72 years. He had a heart murmur and irregular heart beat since childhood. He was asymptomatic. He was put on coumadin at 72 and it changed his life to one of fatigue and muscle aches. 15 years later he has developed a blood cancer. I can only think they are related.

I am 80 and was prescribed Warfarin after I fell and injured my knee. I had pain in my knee which spread to my calf and the knee pain was also increasing. I went to my doctor who ordered a test which indicated a blood clot, and to stop Celebrex And Ibuprufin. After three weeks on this stuff I had no relief from the pain because I counln't take the Celebrex for my arthritis and shoulders, one of which had a surgically installed ball joint and the other has its all cartilage, became tired and very depressed, lost energy, became continually nauseous, sleepy yet sleepless, and limped with great pain in that knee. I felt life wasn't worth living this way and after 7 weeks risked quitting the Warfarin dspite advice to the contrary. I returned to Ibuprufin and Celebrex and the knee pain is subsiding slowly but I at least can walk.

Subscribe

Disclaimer

1. The cases and stories described on this blog are a fictional creation of the author. Many "facts" gleaned from the author's experience as a general surgeon have been altered for instructional and literary purposes. In no way are any of the stories told on this blog non-fictional accounts of actual patients.

2. By entering this blog, you agree to acknowledge that the author does not provide any medical advice and any medical information obtained from the blog is in no way a substitute for an evaluation by real health care professional.

3. Any opinions of the Author on the Site are or have been rendered based on specific facts, under certain conditions, and subject to certain assumptions, and may not and should not be used or relied upon for any other purpose, including, but not limited to, for use in or in connection with any legal proceeding.

4. The Site is protected by United States copyright laws. The Author hereby reserves any and all intellectual property rights in the Site.

5. Courtesy is expected when you decide to post comments. Be nice. Act like a jackass and I'll have to delete you.